Person-centered care

Five years after his retirement from the Army, Leonard Strazza moved past a litany of job rejections and found his groove as an entrepreneurial DJ running a budding entertainment company.

Then something happened in April that nearly cost the onetime combat medic his newfound livelihood: The engine failed on his black 2011 GMC Terrain — the SUV he’d relied on to get to weddings and gigs across the Northeast.

AMP Entertainment owner Strazza, 34, of Bethel Park reached out to a new veterans-needs clearinghouse he’d learned about called Greater Pittsburgh PAServes, a coordinated network of public, private and nonprofit groups seeking to overhaul how veterans find and receive services across Western Pennsylvania.

Two weeks later, Strazza received a $1,000 check to offset repair costs and keep his business going. He’s encouraged by what could be a “tremendous help” for local veterans as the PAServes network grows.

“The biggest problem still is and always has been veterans not knowing the organizations that are out there to help them,” said Strazza, who served 13 years in the Army before retiring in 2011 because of combat-related injuries.

PAServes, a network of veterans services providers overseen by the Pittsburgh Mercy Health System, uses an online case management system to collect, track and follow up on a range of requests from veterans and their families, starting with a focus on Allegheny, Butler and Westmore­land counties.

The goal is to make it easier, more efficient and more effective for veterans to navigate what can be an overwhelming and disjointed web of resources available from more than 170 nonprofits in Allegheny County alone.

Since its October launch, PAServes’ 37 providers and three full-time employees have assisted 622 veterans and family members with a wide range of needs, from employment, health care and housing to fitness, mentoring and volunteering. The network has added an average of 180 clients a quarter, with expanding into neighboring counties and reaching post-9/11 vets among its biggest challenges.

“Nine months in, we’re just very excited with the growth,” said Jean Coyne, director of PAServes’ Greater Pittsburgh Coordination Center and director of intervention services for Pittsburgh Mercy. “The biggest challenges are hitting the transitioning veteran, the younger veteran, the female veteran and reaching out to that population. We have to find creative, strategic ways to reach out to them.”

The PAServes region is among eight U.S. markets testing or planning to try the model using guidance and technology from AmericaServes, a project of Syracuse University’s Institute for Veterans and Military Families.

“We’ve got a fantastic opportunity here,” said Jerry G. Beck Jr., deputy adjutant general of the Pennsylvania Department of Military and Veterans Affairs. “The long-term plan is to get the whole state linked up, but it’s going to take some time. We can learn from what we’re doing in Pittsburgh and apply it to Philly and other areas.”

Allegheny County is home to more than 91,000 veterans — almost 10 percent of veterans statewide, Veterans Affairs data show. Westmoreland has about 34,000 veterans, and Butler County has about 15,000.

So far, AmericaServes representatives said, PAServes stands out nationally for cultivating broad support among providers and having the most active local Veterans Affairs office participating in the program. Pittsburgh VA’s office has trained at least 12 employees in the PAServes system and referred 135 cases to the network.

Family support — such as needing furniture or child care — has accounted for a surprisingly sizable one-third of service requests, Coyne said. Housing, employment and financial aid are in high demand.

“I want to cry,” said Antonio Cersosimo, 25, of Brentwood, who served two years in the Marine Corps and used PAServes to connect with the South Side-based Veterans Leadership Program, which helped him, his pregnant girlfriend and 2-year-old daughter find temporary housing. “For years, I haven’t been able to hold a job. … To have this place to raise my kids and be stable just for a little bit, it’s the greatest thing.”

The Heinz Endowments spurred the creation of PAServes with a $50,000 planning grant in 2014 and a $300,000 contract in 2015 awarded to Pittsburgh Mercy. The program operates on a two-year budget of about $850,000.

Person-centered care is a philosophy and approach to the delivery of health and human services that views the person as a true partner in their own care and considers all aspects of their lifestyle, goals, preferences, and values toward developing the most appropriate plan for their unique circumstances. Providers who use a person-centered approach recognize that all aspects of a person’s life are inter-connected and co-dependent, and this approach can help people to have positive control over their life and feel valued and supported by a web of relationships within their communities. (1)

Balancing Important To & Important For

One of the core person-centered skills providers can practice is sorting out what is important to the person being served, and also what is important for them, and then finding the balance between. (2)

We’ve all experienced a time when someone in our lives has a problem, and we can clearly see a solution. Though we may believe it is in their best interests, the person will not embrace and act on a solution if they don’t agree with or value it. Similarly, services delivered in such a way that they only address what is important for a person (e.g. issues of health and safety, or what others see as being important for the person) and ignore what is important to them, will likely be ineffective. These kinds of programs won’t help people to gain and maximize positive control over their lives, or help them in sustainable ways that work for their lifestyle. (3)

It’s an Industry Standard… In Theory

People who work at social services organizations often describe their organization and services as “person-centered,” “client-centered,” or “patient-centric.” They talk about their Individualized Service Plans, and how important it is that a person share in the development of their plan and the goals it contains. We’ve seen that providers actively strive to deliver a person-centered service experience. At the heart of what they do, providers aim to help people lead full and healthy lives, and most understand that a person-centered approach (if practiced diligently) can help the people they’re serving to achieve those outcomes. So in theory, person-centered care is simply a given for anyone in social services who has genuine respect and regard for the people they’re serving. If most of the industry agrees on this, why are so many service providers unable to achieve person-centered care in practice?

Technology, Systems, and Processes Impact the Practice of Person-Centered Care

Even the most well-intentioned providers are using technology, systems, and processes that prevent them from fully realizing their goals of person-centered service delivery. The technology an organization uses to manage caseloads, the systems used to route phone calls and schedule appointments, the way that information flows throughout the organization, and the set of data being collected about the person served – these are all examples of technology, systems, and processes that directly impact the way that services are delivered by an organization.

Many of the tools being used in social services today aren’t inherently bad tools, they just weren’t designed for person-centered care. In many cases, they weren’t designed for care at all! It’s no wonder that providers can’t reach their full potential when the tools that are meant to support their work actually make it more difficult.

Just as technology and processes can hinder person-centered care, they can also promote and reinforce it. A comprehensive solution designed for person-centered care can get an organization much of the way toward achieving their goals and improving the service experience of people in their care. While tools and technology will never replace the human element of providing care, they can optimize and enrich it. The tools an organization chooses to use define and reflect their values, and those values are reinforced with both staff and persons served every time someone interacts with those tools (think: all day, every day!).

Service Providers: If you describe your services as being person-centered, we challenge you to evaluate how your technologies, systems, and processes help or hinder your approach. If they hinder your approach, it may be time to assess tools and technology specifically designed for the person-centered care you aim to deliver.

1-3 This blog post includes person centered concepts, principles and materials used with permission from The Learning Community for Person Centered Practices. Find out more at www.learningcommunity.us

Stress. We all feel it, especially when life starts to transition and change. Attempting to find assistance with housing, employment, healthcare, or legal services is difficult and complex; often, service organizations are disconnected, siloed and resource-strapped – adding more stress to an already stressful situation.

We can begin to fix this by adopting a modern technology approach to providing human services that speak to the experiences of the consumers and those delivering the assistance. It’s not only a technology fix or a community fix, it takes both, working together to minimize frustration and to finally put people at the center of their own care.

So where do we start? Below are 5 steps Unite US believes offer a new way of delivering social services.

Step 1: There needs to be No Wrong Door – Our research and data taken from our networks in New York, NY (NYServes), Charlotte, North Carolina (NCServes) and Pittsburgh, PA (PAServes) shows that most individuals who are transitioning in life, like Veterans re-entering the civilian world, need more than one social service when they are seeking help. Regardless if the individual requires healthcare and employment and housing assistance, they shouldn’t have to worry about struggling to find the right contact. Resources DO exist to support their needs so why does a door have to close in anyone’s face? In a coordinated network, every service organization is a point of entry and community partners are connected to one another, enabling resources to be more easily found and accessed. Networks create organization, help client eligibility become more seamlessly matched with the right provider and starts to take some of that stress off of the client.

Step 2: Readily available, online access – In today’s world, consumers are accessing everything from their news to their bank account to their doctor with digital lines of communication. Why should social services be any different? Irregular office hours, busy waiting rooms and just the thought of antiquated lines of communication could make you break out in a sweat. A common platform with the right software tools allows service providers to do their job in record time and results in the capture of more client data and the ability to reference that information on demand. Now, the team of practitioners supporting an individual can work together; optimizing care and outcomes for their shared client.

Step 3: Understand the client’s needs entirely and create referrals – Service organizations are there to help members of the community and it’s understandable wanting to be the “one-stop-shop.” But it hasn’t proven to be effective; one social worker or organization cannot do it all. Organizations lose the ability to focus on their key strengths as they expand to be reasonably good at everything. Coordinated networks establish an organized web of care to allow social workers and organizations to easily refer their clients to reliable partners who invest in the core strengths of their programs. Collaboration spurs the interconnection of trusted Network service providers, making sure no one falls through the cracks.

Step 4: You made the referral, rest easy with tracked results – How many people are being assisted? What resource needs should the community prioritize? If your city or state doesn’t know this information, how can they help? Unite US technology removes the guesswork and delivers data to Network members and community leaders, so the needs of the public can be assessed and organizations can begin on focusing on areas that need improvement.

Step 5: The forever after means optimized service for everyone involved – Accountability is a critical factor in ensuring that whoever is assisting a particular individual actually follows through with what they say they’re going to do, and that their success is directly measured against meeting their needs and the needs of the wider community. Collectively, organizations within a community can make an impact and move the needle by optimizing service starting at the individual level.

The bottom line is that community involvement, collaboration and technology are driving a new, streamlined approach to delivering social services – reducing stress and putting the individual or their loved ones at the center of their own care.

Disorganized. Frustrating. Time-consuming. Demoralizing. We’ve all felt these and a host of other emotions when navigating healthcare, financial, legal, employment, and other essential services that should be easy to access —but aren’t. It doesn’t have to be this way.

Coordinated Care Networks create a streamlined process for people seeking assistance, and also for those providing services. Service providers participating in a Coordinated Care Network can connect their clients with a larger range of reliable services than they can while operating alone. Hospitals are some of the first places we’ve seen coordinated care succeed in both saving lives and cutting costs.

The challenge is bringing together the wide variety of services that people need onto a common platform so that service providers can work together to holistically meet all of the needs a person has during different points in their life, whether that is a single need like housing, or multiple related and complex needs.

Veterans in several regions of the country are now some of the first to benefit from a coordinated care approach. Coordinated Networks in North Carolina, New York City, Western Pennsylvania and Illinois connect dozens of service providers offering Veterans services, enabling transparency and coordination of care across multiple organizations. These networks empower Veterans, allowing for easier access to services while affording data-driven outcomes and insights to these communities.

This proven Coordinated Care model must be replicated across the United States, both for Veterans and all individuals who need a variety of health and human services. Below are the top 5 reasons that we believe in coordinated care networks:

1. “Person-Centered Support Strategy”: Service providers can identify needs across functional categories of service and collaborate to support their shared client in parallel.

2. “Service Optimization”: Because Coordinated Networks enable transparency of all the available resources in a community, service providers better understand the most appropriate, available services to support the needs presented by their client, especially when the client has needs outside the scope of their programs’ service offerings.

3. “No Wrong Door”: Veterans may access the network in a number of ways, such as walking into a participating service provider, or via phone call, email, or web. No matter which door the Veteran enters, they will be guided to the best available services to meet their unique needs.

4. “Accountability and Insights”: Coordinated Networks provide real-time data on services offered and rendered, provider performance and client satisfaction, and insight into needs and service gaps within a community. Participating service providers have access to a wealth of data specific to their organization and the outcomes they’ve achieved by coordinating with other providers in the community.

5. “Improved Veteran Experience” – When service providers work together to offer a Person-Centered Support Strategy that is Optimized for Best-Fit Services at the first intake, the service experience for the Veteran client is drastically improved. A positive experience for the client leads to greater client retention in services and better outcomes for service providers and the community at large.

Read more about how technology helps Veterans and the non-profit service industry, here.

NEW YORK, Aug. 5, 2015 /PRNewswire/ — Unite US, a health & human services software company, is revolutionizing how citizens connect with local resources, services, and care, with an initial focus of serving a demographic close to their heart: Veterans and Military Families. The company, focusing on care coordination and the delivery of supportive services, recently secured a $4.3MM Series A round, bringing their total funding to $6.3MM. Investors in the round include Omidyar Network, New York Ventures, Scout Ventures, Granger Management LLC, and previous seed investors.

“When we started, we saw massive fragmentation, which increasingly disconnected Veterans and dedicated support organizations. This led us to be laser focused on creating the most streamlined connections between consumers and the services they are seeking,” said Dan Brillman, CEO of Unite US. “We exist to help organizations and communities build scalable and sustainable infrastructure to support the needs of their constituents. With integrated and centralized tools, organizations can be more accessible, operationally efficient, and collaborative.”

Unite US is the exclusive technology provider powering NYC Serves, the first coordinated network of service providers in New York City, with over 40 public and private organizations and 200 practitioners working together to deliver coordinated care for the city’s Military population. The platform allows coordination and secure referrals enabling multiple agencies to serve clients simultaneously, while maintaining accountability, and providing outcome tracking and analytics for the services delivered.

This network model, which has since expanded to North Carolina and Pennsylvania, includes the Department of Defense, Department of Veteran Affairs, academic institutions, non-profits, and private services, all working together to provide a single point of entry for Veteran services.

“We are proud to support the Unite US team in their mission to address the very real and immediate needs surrounding care within the Veteran community,” said Brad Harrison, Managing Partner of Scout Ventures, “Unite US has developed a robust and dynamic platform that provides the tools and resources that Veteran care organizations need in order to more efficiently connect with Veterans and their communities at large.”

Unite US, which has over 1000 users accessing their software and upwards of 100,000+ users on their consumer platform, is looking forward to powering over 25 city and state coordinated networks and help organizations and government use real-time data to measure collective impact and better understand the needs of service-members, Veterans, and Military families.

About Unite US
UniteUS.com provides a free resource network connecting current military service members, Veterans and their families to transformative resources and opportunities in their local communities. With its interactive, proximity-based technology, Unite US members and organizations are able to seamlessly connect with resources, each other, and services based on need and location.

Unite US empowers organizations and communities with centralized cloud-based organizational and care coordination software tools to effectively communicate and manage their services. Unite US endeavors to partner with communities, agencies, and services to implement seamless solutions to empower providers and service-members, Veterans and their families.